The “Other” Headaches: Primary Cough,Exertion, Sex,and Primary Stabbing Headaches

Primary cough headache, primary exertional headache, primary sexual headache, and idiopathic stabbing headache are included in “Other Primary Headaches” (Group 4) in the International Classification of Headache Disorders, 2nd edition (ICHD-II). Headaches provoked by cough, exertion, and sex have different age distributions, but they do share some clinical and pathogenic characteristics. The triggering activities frequently involve Valsalva-like maneuvers, which may explain part of the pathogenesis. Primary stabbing headache is common and characterized by ultra-short stabbing headaches. All these headache disorders respond well to indomethacin, and they are commonly comorbid with migraine except for primary cough headache. Of note, some patients with sexual headache had reversible cerebral vasoconstriction syndromes. Recent large-scaled studies have revealed that the ICHD-II criteria of these four headache disorders cannot be completely fulfilled. Further revisions for the ICHD-II criteria are required based on these results of the evidence-based studies.     

Sufficiency and Necessity in Migraine: How do we Figure Out if Triggers are Absolute or Partial and,if Partial,Additive or Potentiating?

Primary stabbing headache (PSH) is an under-recognized primary headache disorder, which often goes undiagnosed. It is mainly characterized by its ultrashort stabbing quality and can be easily overlooked both by patients and providers as it is often not severe enough to interfere significantly with daily life. However, PSH may be severe and require therapy, and it is important for providers to recognize this headache type, both in adult and pediatric populations, as well as to be able to distinguish it from secondary headache disorders. PSH also may be more common than previously thought.     

Paroxysmal stabbing headache in the multiple dermatomes of the head and neck: a variant of primary stabbing headache or occipital neuralgia?

A paroxysmal stabbing or icepick-like headache in the multiple nerve dermatomes, especially involving both trigeminal and cervical nerves, has not been fully explained or classified by the International Classification of Headache Disorder, 2(nd) Edition (ICHD-II). Of patients with acute-onset paroxysmal stabbing headache who had visited the Hallym University Medical Center during the last four years, 28 subjects with a repeated stabbing headache involving multiple dermatomes at the initial presentation or during the course were prospectively enrolled. All patients were neurologically and otologically symptom free. A coincidental involvement of both trigeminal and cervical nerve dermatomes included seven cases. Six cases involved initially the trigeminal and then cervical nerve dermatomes. Five cases showed an involvement of the cervical and then trigeminal nerve dermatomes. The remaining patients involved multiple cervical nerve branches (the lesser occipital, greater occipital and greater auricular). Pain lasted very shortly and a previous history of headache with the same nature was reported in 13 cases. Preceding symptom of an infection and physical and/or mental stress were manifested in seven and six subjects, respectively. All patients showed a self-limited benign course and completely recovered within a few hours to 30 days. Interestingly, a seasonal gradient in occurrence of a stabbing headache was found in this study. A paroxysmal stabbing headache manifested on multiple dermatomes can be explained by the characteristics of pain referral, and may be considered to be a variant of primary stabbing headache or occipital neuralgia.     

Clinical features of unilateral headaches beyond migraine and cluster headache and their response to indomethacin

The majority of previous studies on unilateral headaches beyond migraine and cluster headache have focussed on certain disorders such as paroxysmal hemicrania, SUNCT and primary stabbing headache. We assessed headache characteristics, importance of neuroimaging and response to indomethacin in an unselected series of uncommon unilateral headaches. We investigated all consecutive patients presented with unilateral headaches not fulfilling ICHD-II criteria of migraine and cluster headache. Patients underwent cranial magnetic resonance imaging or computed tomography as well as an indo-test, i.e. oral indomethacin 75 mg b.i.d. for 3 days. Among 63 patients we diagnosed primary stabbing headache in 12 patients, (probable) paroxysmal hemicrania in 6 and tension-type headache in 3 patients. One patient each had probable SUNCT, new daily persistent headache and nasociliary neuralgia. Eight patients had a secondary headache and 31 could not be classified according to ICDH-II. Imaging revealed lesions causally related to the headache in 8 patients. Indo-test achieved full remission of headache in 13 of 51 patients. At follow-up 11 ± 3 months after the first visit 29% of the patients were headache-free for ≥3 months. In conclusion, almost half of the patients presented with unilateral headaches beyond migraine and cluster headache cannot be classified according to ICHD-II. Among classifiable headaches primary stabbing headache was the most common. Imaging should be considered to rule out secondary headaches. The course is favourable in one third of the patients.     

Short-lasting headaches in children

Short-lasting headaches have been studied infrequently in children and it is not known if the main categories of primary headaches of this type in adults are applicable to children. We report our experience with a group of 20 children with a brief headache. Two patients had a secondary headache. One patient had a headache with some clinical characteristics of paroxysmal hemicrania. The remaining 17 had a very brief headache. They were in many aspects comparable to others from previous studies on idiopathic stabbing headache in children: no associated symptoms, no other associated headache, frequent family history of migraine. They differed, however, in the younger age of the patients and the more frequent extratrigeminal location of the pain. Extratrigeminal ice-pick pain may be a variant of idiopathic stabbing headache, more prevalent in young children.     

Transient stabbing headache from an acute thalamic hemorrhage

Stabbing headache can be encountered in both primary and secondary forms, but has been infrequently reported among patients with stroke, and is not known to be associated with a small well-circumscribed brain lesion. A 95-year-old woman taking warfarin presented with the sudden onset of stabbing headache strictly in the right frontal and supraorbital regions, along with gait imbalance and dysarthria. Neuroimaging revealed a small left thalamic hematoma. This association of an acute thalamic lesion with stabbing headache in the contralateral trigeminal distribution is discussed, along with a brief review of stabbing headache occurring in cerebrovascular disease.     

New Onset Focal Stabbing Headache Associated With Peripheral Vertigo: A Case Report

We present a novel case of a focal stabbing headache sharing features of primary stabbing headache that started and resolved with the onset and resolution of a course of self‐limiting peripheral vertigo. The association of onset and improvement of the stabbing headaches support the trigeminal and vestibular reciprocal relationships. Vestibular input may be the driving force and a potential target for treatment.     

Primary and Secondary Stabbing Headache

Eight out of the 33 cases of primary stabbing headache seen in a general neurology clinic (40% have headache as their chief complaint) in the last 3.5 years are presented. The epidemiology, association with other primary headache disorders, secondary associations, testing, and treatment of primary stabbing headache are reviewed.     

Juvenile Idiopathic Stabbing Headache

We report on 83 juvenile patients with idiopathic stabbing headache, subjectively perceived as lasting from a fraction of a second to a few minutes. This sample was selected from among 2543 outpatients referred because of recurrent headache to the Paediatric Neurology Services of Ferrara and Padua (Italy). Other painful syndromes were excluded by clinical examination and appropriate tests Idiopathic stabbing headache in the pediatric age group contrary to the adult form, is usually not associated with other primary headache syndromes. We suggest that this clinical picture should be more clearly defined in the future, in order to better understand its relationships with other primary headaches.     

Verschiedenartige Kopfschmerzformen des Kapitels?4 der Internationalen Kopfschmerzklassifikation

Chapter 4 of the International Classification of Headaches contains a group of clinically very heterogeneous primary headache forms. Little is known about the pathogenesis of these headache types and therapy is usually based on isolated case reports and uncontrolled studies. The forms include primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua and the new daily persistent headache. Some of these headache forms may be of a symptomatic nature and require careful examination, imaging and further tests. Primary and secondary headache forms must be carefully distinguished.     

Other primary headaches

Most primary headaches are classified into a few categories, such as migraine or muscle contraction headache, and patients suffering from these headaches are common. On the other hand, other primary headaches are very rare. In this section entitled "Other primary headaches", eight headaches, including primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua, and new daily-persistent headache, are described. Some characteristics of other primary headaches are common in symptomatic headaches, such as subarachnoid hemorrhage or arterial dissection. Therefore, careful evaluations including neuroimaging are necessary to exclude organic diseases.     

Melatonin responsive hemicrania continua

Hemicrania continua is one of the indomethacin-responsive headache syndromes. There are very few effective alternative therapies for hemicrania continua, thus patients may require daily indomethacin for years. The risks of long-term indomethacin include gastrointestinal and renal dysfunction. Melatonin is a pineal hormone with a chemical structure very similar to indomethacin. Recently, melatonin was shown to be effective for primary stabbing headache, another indomethacin-responsive syndrome. Three cases of melatonin responsive hemicrania continua are now reported.     

Brief Sharp Stabs of Head Pain and Giant Cell Arteritis

Giant cell arteritis (GCA) should be considered in the differential diagnosis of any new onset headache occurring in individuals over the age of 50 years. Headache is the most common complaint in GCA patients but the clinical characteristics of the headache itself does not help in making a diagnosis as the headache can occur anywhere on the head, not just the temples, be mild to severe in intensity and be dull to throbbing in quality. As other things can cause new onset headache in older individuals, additional clinical symptoms or signs that may suggest GCA as a diagnosis would be useful to clinicians. Two cases are presented that suggests that new onset stabbing headache associated with a new daily persistent headache is a possible diagnostic sign for a diagnosis of GCA. Nothing in the literature to date has mentioned new onset stabbing headache as part of the presenting symptom complex for GCA.     

Indomethacin-responsive headache syndromes

Indomethacin-responsive headache syndromes represent a unique group of primary headache disorders characterized by a prompt and often complete response to indomethacin to the exclusion of other nonsteroidal anti-inflammatory drugs and medications usually effective in treating other primary headache disorders. Because these headache disorders can easily be overlooked in clinical practice, they likely are more common than previously recognized. Indomethacin-responsive headache syndromes can be divided into several distinct categories: a select group of trigeminal-autonomic cephalgias, valsalva-induced headaches, and primary stabbing headache (ice-pick headache or jabs and jolts syndrome). Each category can be differentiated clinically and by the extent to which the individual headache disorders respond to indomethacin. The paroxysmal and continuous hemicranias invariably respond in an absolute manner to indomethacin, whereas valsalvainduced and ice-pick headaches may respond in an equally dramatic, but somewhat less consistent fashion. Hypnic headache recently has been described as another primary headache disorder that may respond to indomethacin.     

Primary stabbing headache in a headache clinic

Primary stabbing headache (PSH) is a short-lasting but troublesome headache disorder which has been known for several decades. We surveyed and registered consecutive patients with PSH in a headache clinic in Taiwan. A total of 80 patients (24 M/56 F, 53.2 +/- 16.2 years) were enrolled in our study. Migraine was reported in 20 (25%) patients and was less common in those with PSH onset at >50 years than those with onset at <50 years (14% vs. 38%, P = 0.02). The headache was unilateral in 59% of the patients and always in a fixed area in 36%. The head pain frequently involved extratrigeminal regions (70%) and in 30 patients (38%) was accompanied by jolts, i.e. head or body movements. Indomethacin was effective (74%) in patients who received it. Our study showed primary stabbing headache was a common and easily treated headache disorder in headache clinic. However, 70% of our patients could not fulfil criterion A 'exclusively or predominantly in the distribution of the first division of the trigeminal nerve' and 15% could not fulfil criterion C 'no accompanying symptoms' of the International Classification of Headache Disorders-II criteria proposed for PSH.     

CLUSTER, NEURALGIAS, AND TACS

A number of primary headache syndromes are marked by their short duration of pain. Many of these syndromes have their own unique treatment, so they must be recognized by practicing physicians. In this article, a number of the short-lasting headache disorders are reviewed, including chronic paroxysmal hemicrania, SUNCT syndrome, hypnic headache, exploding head syndrome, primary stabbing headache, and cough headache.     

Short-lasting headache syndromes and treatment options

A number of primary headache syndromes are marked by their short duration of pain. Many of these syndromes have their own unique treatment, so they must be recognized by practicing physicians. In this article, a number of the shortlasting headache disorders are reviewed, including chronic paroxysmal hemicrania, SUNCT syndrome, hypnic headache, exploding head syndrome, primary stabbing headache, and cough headache.     

Chronic daily bilateral headache responsive to indomethacin

Indomethacin is known to be specifically effective for chronic paroxysmal hemicrania, episodic paroxysmal hemicrania, and hemicrania continua. Different forms of idiopathic stabbing headaches have also been responsive to indomethacin, but less consistently than the others. Two cases of indomethacin-responsive headache are reported. One patient presented with what appeared to be new-onset, chronic, daily, bilateral headache aggravated by coughing. Both the chronic daily headache and the exacerbations induced by coughing were suppressed with indomethacin therapy. The second patient experienced hemicrania continua responsive to indomethacin, and the response persisted even when the headache evolved into bilateral continuous pain. There may be other idiopathic primary headache disorders that are peculiarly responsive to indomethacin. When any primary headache disorder does not respond to standard therapy, a brief therapeutic trial of indomethacin is warranted.     

Ice Pick Headache

Ice pick headache, also called idiopathic or primary stabbing headache, is a unique headache type associated with ultra-brief stabs of pain, most commonly in the frontal or temporal area. It occurs predominantly in women and is estimated to affect 2–35 % of the population. Unlike other headache types of short duration, such as short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), ice pick headache is not associated with any cranial autonomic symptoms but has been known to occur with nausea, vomiting, photophobia, and dizziness. It exists in two forms: primary and secondary, with examples of secondary causes being herpes zoster meningoencephalitis, meningiomas, stroke, and multiple sclerosis. Ice pick headache is one of the “indomethacin responsive headaches,” but up to 35 % of patients fail to show significant benefit with that treatment. Other treatment options include gabapentin, cyclooxygenase-2 inhibitors, melatonin, and external hand warming.     

SUNCT: a new case with some unusual features

A healthy 22–year–old man complained of primary stabbing headache (PSH) for about two months. The headache recurred after one year and after a month the pain took on the characteristics of short–lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). This patient shows some unusual features: juvenile onset, miosis during attacks as part of autonomic phenomena and close temporal relationship with stressful events. The association between PSH and SUNCT may be interpreted as the coexistence of two different headaches or that the PSH is a forerunner to the SUNCT.